EmblemHealth Coverage for Physician Assistant Services

Date Issued: 7/17/2013

EmblemHealth Coverage for Physician Assistant Services
The professional services of a physician assistant (PA) may be covered in network if he or she is contracted, meets the qualifications listed below and is legally authorized to provide services in the state where the services are performed.

Payments are allowed for assistant at surgery services and services provided in all areas and settings permitted under applicable state licensure laws, but only if no facility or other provider is paid with respect to the provision of such professional services.

Qualifications for PAs
A PA must meet the following qualifications:

  • Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs [CAAHEP] and the Committee on Allied Health Education and Accreditation [CAHEA]) or
  • Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA) and
  • Be licensed by the state to practice as a PA

Covered Services
Services are covered if they meet all four of the following criteria:

  • Considered physician’s services if provided by a doctor of medicine or osteopathy (MD/DO)
  • Performed by a person who meets all the PA qualifications and is legally authorized to perform the services in the state in which they are performed
  • Performed under the general supervision of an MD/DO
  • Not otherwise precluded from coverage because of one of the statutory exclusions.

Types of PA Services That May Be Covered
PAs may provide services billed under all levels of CPT evaluation and management codes, and diagnostic tests, if furnished under the general supervision of a physician. Examples of services that PAs may provide include services traditionally reserved to physicians, such as examinations (including the initial preventive physical examination), minor surgery, setting casts for simple fractures, interpreting X-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition.

Services Otherwise Excluded From Coverage
PA services may not be covered if they are otherwise excluded from coverage even though a PA may be authorized by state law to perform them.

Physician Supervision
The PA’s physician supervisor (or a physician designated by the supervising physician or employer as provided under state law or regulations) is primarily responsible for the overall direction and management of the PA’s professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present with the PA when a service is provided to a patient and may be contacted by telephone, if necessary, unless state law or regulations require otherwise.